ure there is a corresponding change in the physical side. All the signs of age which I have already mentioned become accentuated until they reach, as Shakespeare says, the stage of

"Second childishness and mere oblivion,

Sans teeth, sans eyes, sans taste, sans everything."

The condition described is usually called senile deterioration but when confusion becomes a prominent symptom, the condition is spoken of as senile confusion. This confusion is apt to be accompanied by restlessness, especially at night, when if not watched they will wander about the house putting the other occupants in danger from their likelihood of setting the premises on fire or doing other acts of mischief. They are usually disoriented and can not tell where they are nor the time of day. They are apt to wander away and become lost and thus are a danger to themselves. In some instances of senile deterioration there may be marked depression and agitation with a tendency to suicide.

When the persecutory delusions become marked, we may have a true paranoid condition with hallucinations of hearing and all the accompaniments of paranoia.

Among the physical symptoms that may develop during the course of senile deterioration are apoplexy, apoplectiform attacks, and senile epilepsy. Chorea, of the Huntington type or the post-apoplectic variety, is not infrequently observed. This condition is especially marked upon awakening from sleep as the cerebral circulation through the diseased vessels is slow to adjust itself to change from the sleeping to the waking state.

In addition to the types already mentioned we may have a senile delirium, characterized by fleeting delusions, multiform hallucinations, clouding of consciousness, great incoherence, and marked motor restlessness or occupation delirium. This condition may suddenly develop in a case which has been following the usual course and when it does it is usually found to be due to some bodily cause such as pneumonia, nephritis, cystitis, etc., or it may occur as an episode in any case of senile psychosis, in which case it is

apt to clear up, while if it occurs as a manifestation of a terminal infection, it is apt to be fatal. In "A study of 200 cases of senile dementia, Dr. William Pickett gives the following list of symptoms which he found in their order of frequency: "A tendency to wander; hallucinations; a tendency to violence; vertigo; persecutory ideas other than poisoning; conspiracy, etc.; exaltation; night prowling; apoplectiform strokes; headache; suicidal attempts; suspicion of conspiracy; suspicions of poisoning; violence at night; epileptiform attacks; delusions of infidelity; setting fire to things; echolalia; chorea."

In addition there are the physical symptoms due to arteriosclerosis, disturbances of the functions of the various viscera, sleeplessness, etc.

An appreciation of these various symptoms will show how necessary it is for cases of senile insanity to have the care and nursing which can only be had in a modern hospital for the insane. To prevent accident or injury to themselves or others, constant attention both day and night is necessary, and their often untidy habits call for the same attention that is given to a helpless child. Their physical condition requires hygienic surroundings and an appropri

Their insomnia needs an appropriate hypnotic or the careful administration of a suitable quantity of alcohol, but neither measure should be resorted to except under medical supervision as such patients are very susceptible to the influence of drugs and alcohol and easily form habits which it may be difficult or impossible to break. The arterial tension needs careful attention and appropriate remedies and the functions of all the viscera need careful watching and suitable treatment. I can not, therefore, be too emphatic in calling your attention to the danger of attempting to care for cases of senile insanity in county houses or almshouses where efficient nursing and appropriate medical attention are not, under all circumstances, immediately available.

Even home care should not be attempted in a case of senile insanity unless hospital conditions can be closely approximated. If the patient can be provided with a sunny

room with constant nursing day and night and with suitable diet and diversion, then home care may be attempted. But if the surroundings are poor and if the nursing must be done by those who are engaged during the greater part of the time in other occupation, then harm is apt to come to the patient while the other members of the family who are subjected to the additional strain which the care of such a case involves are apt to break down, both physically and mentally, and thus add to the existing troubles. Therefore let me again repeat my warning against any attempt at home treatment or almshouse care for the senile insane.

As I have already said, to the majority of the poor, old age is full of trials and tribulations and when to the ordinary disabilities of senility we have added the mental and physical symptoms of insanity, the condition is one that calls for our tenderest sympathy and kindest care, and we should ever bear in mind the pathetic words of the psalmist: Cast me not off in the time of old age; forsake me not when my strength faileth."

66

A PLEA FOR THE EXTENSION OF THE

PAROLE PERIOD

By M. B. HEYMAN, M. D.,

Assistant Superintendent, Central Islip State Hospital.

The practice of paroling patients from hospitals for the insane is so widespread and satisfactory that no one acquainted with the facts would wish to have it discontinued. It is both humanitarian and economic-enlarging the liberty of the patients, safeguarding their interests, encouraging their self-respect, and at the same time saving money for the State.

Under the present regulations our hospitals are authorized to parole patients for a period of six months. This period can be extended by having the patient returned to the hospital and reparoled. However, there seem to be many arguments why a parole period of at least one year should be instituted. On account of the European war now raging, the difficulty of deporting the alien insane has increased and the overcrowding that has resulted, especially in the metropolitan hospitals, can only be relieved by extending the parole system to its fullest extent.

One distinct advantage that follows parole is the change of attitude of the patient to the hospital officials and his friends. A few days or a few weeks on parole from the hospital will frequently change a hostile attitude into one of a more friendly disposition and the patient may willingly return to the hospital and submit readily to the rules and regulations that previous to parole were considered unreasonable and irksome.

The border line cases are the ones that chafe most under confinement and a short leave of absence among their friends does a great deal to establish confidence in the authority against which they naturally rebel. Patients suffering from periodic insanity and those with remissions from a progressive form may be paroled with advantage to all concerned and if the period of parole were extended to one year might be returned without the trouble and expense of recommit

ment. By consulting the discharge records of the several State hospitals for a number of years back it is very noticeable that a large number of cases have been discharged "much improved" and "improved." Some of these patients regain their normal mental standard after reaching home. However, many of them have psychopathic personalities or have a deteriorating psychosis. This pertains especially to cases of dementia præcox in which we know that remissions of the mental disorder are not uncommon, oftentimes an improved mental condition lasting several months. This also occurs in cases we describe as "mental deficiency." It is also true of the constitutional disorders like manic-depressive insanity. With the præcox cases, however, the improvement is usually only temporary or evanescent and sooner or later it is necessary to return them for further treatment. It will be apparent to all that an argument for a longer parole period applies especially to cases of the alcoholic type. It would be a most decided restraining influence on this type to inhibit their desire for alcoholic stimulants if they knew they were under the jurisdiction and control of the hospital for a year or longer. This has been brought most forcibly to the attention of our aftercare agent who has frequently been told by solicitous friends that while the patient was on parole and under the jurisdiction and control of the hospital he felt this restraining influence and would apply himself more industriously and hold a better check on himself, as he was anxious to have a good report made of them to the clinic of the hospital. This idea is also shared in a pronounced way by the relatives themselves. I am sure it is not uncommon that the physicians in our hospitals, in their daily or weekly parole of patients, hear voluntarily expressed by relatives the wish that the patient shall be strongly impressed with the idea that he is not discharged but on parole for a number of months.

We well know that cases of organic diseases, such as paresis and cerebral syphilis, have not uncommonly periods of remission. These remissions, of course, are of varying lengths, some lasting for several months or a year or more,